Athletic Field Use Request 2023

CONTACT INFORMATION

Organization Name	Phoenix Charter Academy
Name of Activity / Event	---
Location (See link to park locations and descriptions above)	---
Other (Write in N/A if not applicable) :	N/A
Applicant Name/Contact Person	---
Email Address	---
Cell Phone	---
Billing Address	---

EVENT INFORMATION

Name of Supervisor on Site	---
Supervisor Phone Number	+16172711675
Name of Second Supervisor on Site	---
Second Supervisor Phone Number	+19785958228
# of Teams in your Organization	---
# of Players in your Organization	---
Total number of people expected	---
Organization Type	---
Activity	---
Brief Description of Activity	Student vs Staff/ Teacher Soccer match
Primary Participants?	Youth
Sport (note: please fill out a separate application for each event)	Soccer
Please note any special requirements here	Soccer Post/goal

First preference for event date

Is this event happening on one date or multiple dates?

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First preference: Two or more dates

Dates	---
Days of the week	Tuesday
Times	4pm

Second Preference?

If your first choice date is not available, do you have a second choice?

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Second Preference information

Days of the week	Thursday
Dates	October 26
Times	4om
Location	Highland Park

Additional Questions

1. Will the event generate admission fee or revenue?	---
1a. If yes, please specify below (Write in N/A if not applicable):	---
2. Will amplification be utilized?	---
3. Will you provide any music or entertainment? If so, apply here: https://go.citygro.ws/the-department-of-licensing-permitting-and-consumer-affairs-chelsea-ma/sample-amusement-entertainment-license-7df35bdf-d54b-45e4-903d-990e2e5694f	---
4. Will there be any use of machinary powered by gasoline, diesel or electricity?	---
4a. If yes, please specify the usage (Write in N/A if not applicable):	---
5. Will food or beverage be provided?	---
5a. If yes, please specify (Write in N/A if not applicable)	---
5b. If food or beverage provided, will it be:	---
6. Will anything be sold at the event?	---
6a. If yes, specify (Write in N/A if not applicable)	---
7. Will you require lighting or access to electrical outlets?	---
8. Will you require use of restrooms, if available?	---

Indemnification/Hold Harmless

Name of Director/President/Group Leader:	---
Date	2023-10-02
I understand that I am completing a binding electronic signature when I submit this form constitutes a legal signature.	Yes

Policy Acknowledgement/Acuse de recibo

Name of Director/President/Group Leader:	Steven Arango
Date	2023-10-02
I understand that I am completing a binding electronic signature when I submit this form constitutes a legal signature.	Yes